Clinical Notation: Documentation for clients in treatment - CASAT

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Our Personal Goal…Help clinicians keep clinical documentationclient-drivenHelp agencies develop consistency withdocumentationHelp with developing a solid understanding ofthe treatment episodeTo learn how clients can be experts, will helpguide treatmentHelp alleviate apprehension regarding thewriting of clinical notations
Page 1: CLINICAL NOTATION:DOCUMENTATION FOR
Page 6 and 7: Outline For Clinical Notation• Cl
Page 8 and 9: Electrical NotationOne goal of this
Page 10 and 11: Who is SAPTA?The mission of the Sub
Page 12 and 13: Module 1• Review of a TreatmentEp
Page 14 and 15: IntroductionTen NOMs Domains• Red
Page 16 and 17: Screening vs. Assessment• Screeni
Page 18 and 19: Assessment• A basic assessment co
Page 20 and 21: Twelve Steps in the AssessmentProce
Page 22 and 23: DSM-IV DiagnosingDSM-IV diagnosis m
Page 24 and 25: Previous DiagnosisBe mindful of co-
Page 26 and 27: Comprehensive Evaluations• Within
Page 28 and 29: ASAM PPC-2RThe American Society of
Page 30 and 31: ASAMWhat is the ASAM not?• The eq
Page 32 and 33: ASAM &Treatment Levels Crosswalk•
Page 34 and 35: Transferring to a Different Levelof
Page 36 and 37: Stages of Change…
Page 38 and 39: Stages of ChangeKey Points:Stages o
Page 40 and 41: Understanding Resistance“…the l
Page 42 and 43: Decreasing Resistance• Find What
Page 44 and 45: Review of M.I.What is MI?Stephen Ro
Page 46 and 47: The Spirit of M.I.We believe it is
Page 48 and 49: Motivational Interviewing Technique
Page 50 and 51: OARSOpen-Ended Questions, Affirmati
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Open-Ended QuestionsOpens dialogue
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Reflections:• Convey empathy and
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How to Summarize• String several
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Reflect ResistanceClinician: And te
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Asking Permission“Asking permissi
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Supervision ReviewReminder: Assessm
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Module 2• Admission• Master Pro
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AdmissionIt is important to be as a
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Treatment PlanningTreatment plannin
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Treatment PlanningIn Brief:First Tr
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Master Problem List cont.Since the
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Treatment PlanningWriting Effective
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Treatment Planning cont.Below are g
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Treatment PlanningNOTE: The treatme
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Changing the Treatment PlanIf you a
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Add ReviewWhen you click on the Add
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ASAM/HDPC & TreatmentPlanningRememb
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Example:“ Sylvia reports abstinen
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Module 3• Progress Notes• Chart
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Progress NotesEvery therapeutic eve
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Progress NotesA progress note is re
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Examples of Observations-EBPExample
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Progress Notes-Intervention“ Revi
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Intervention EBP“Utilize MI and S
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Intervention EBP“Used solution fo
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Intervention-EBP“Used motivationa
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Module 4• Aftercare Plan• Disch
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DischargesDischarges are filled out
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Discharge SummaryWhat is included i
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Signatures, Signatures, Signatures!
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Hard ChartsOrganizedCoincide with e
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Activity 2: You‟re the Supervisor
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In Conclusion….Questions???
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